Orientadores: Marcos Tadeu Nolasco da Silva, Rubens Nelson Amaral de Assis Reimão / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T23:19:37Z (GMT). No. of bitstreams: 1 Gazini_CarinaCaires_M.pdf: 1252210 bytes, checksum: 00b55ba57c9260460ffa328a2940bdb8 (MD5) Previous issue date: 2011 / Resumo: INTRODUÇÃO: O sono é fator indispensável para a saúde integral. Sua má qualidade, em adolescentes, pode resultar em alterações cognitivas, psicológicas e clínicas. Crianças e adolescentes infectados pelo Vírus da Imunodeficiência Humana (HIV) são vulneráveis a apresentar distúrbios do sono, como consequência de alterações imunológicas e emocionais. Com base neste contexto, este estudo teve o objetivo de avaliar as características do sono de adolescentes infectados pelo HIV e verificar a associação entre aspectos psicossociais, clínicos, imunológicos e virológicos e alterações no padrão e na qualidade do sono. CASUÍSTICA E MÉTODOS: Estudo observacional, analítico, prospectivo, do tipo corte transversal. Foram avaliados 222 adolescentes de ambos os gêneros, com idade a partir de 10 anos, sendo 102 infectados pelo HIV (59 rapazes) e 120 estudantes (73 garotas) presumidamente saudáveis. Para a coleta de dados aplicaram-se: Escala de distúrbios do sono em crianças (SDSC), Escala de Sonolência de Epworth (ESE) e Questionário genérico sobre Qualidade de Vida Pediátrica (PedsQLTM4.0). Dados clínicos, imunológicos e virológicos foram retirados dos prontuários médicos. Na análise estatística, utilizaram-se os testes de Mann-Whitney, Qui-Quadrado e o Coeficiente de Correlação de Spearman. Resultados foram considerados estatisticamente significativos se P ? 0,05. O estudo foi aprovado pelo Comitê de Ética em Pesquisa em Seres Humanos da Faculdade de Ciências Médicas da Universidade Estadual de Campinas. RESULTADOS: Verificou-se prevalência de distúrbios do sono, com base nos escores SDSC, de 77,4% nos pacientes e 75% nos controles (P = 0,67). Pacientes infectados pelo HIV apresentaram maior pontuação do escore SDSC nos distúrbios respiratórios do sono com medianas de 3 (3 - 15) vs 3 (3-11) (P = 0,05), e maior pontuação de sonolência diurna excessiva pela ESE, com medianas de 6 (0 - 17) vs 5 (0 - 14) (P = 0,02). Houve correlação entre os escores SDSC e PedsQL em ambos os grupos, com rs = -0,46 no grupo infectado (P < 0,001) e rs = -0,37 no grupo controle (P < 0,001). Não se observaram associações estatisticamente significativas entre os indicadores de qualidade do sono e variáveis clínicas, imunológicas ou virológicas, no grupo infectado. CONCLUSÃO: Os adolescentes infectados pelo HIV apresentaram qualidade do sono semelhante à população saudável, porém com alta prevalência de distúrbios do sono, ocorrendo associação entre qualidade de sono e qualidade de vida em ambos os grupos. Não foram identificados fatores clínicos, imunológicos ou virológicos associados à qualidade do sono, no grupo infectado. Tais resultados decorrem provavelmente da gradual melhora de condições de vida dos adolescentes infectados, resultante do sucesso da terapia antirretroviral, bem como das vulnerabilidades que potencialmente afetam a qualidade do sono em adolescentes brasileiros / Abstract: INTRODUCTION: Sleep is an indispensable feature of integral health. It's bad quality, in adolescents, may result in cognitive, psychological and clinical disturbances. Children and adolescents infected with Human Immunodeficiency Virus (HIV) are vulnerable to present sleep disturbances, due to immunological and emotional abnormalities. Within the above setting, this study aimed to evaluate sleep characteristics of HIV-infected adolescents and to verify the association between psychosocial, clinical, immunological and virological issues and abnormalities in pattern and quality of sleep. PATIENTS AND METHODS: Observational, analytical, prospective, cross-sectional study. Two hundred and twenty-two adolescents from both genders were evaluated, aged 10 or more years-old. One hundred and two (59 boys) were HIV-infected, and 120 (73 girls) were presumedly healthy students. The following tools were used for data collection: Sleep Disturbance Scale for Children (SDSC), Epworth Daytime Sleepiness Scale (EDSS) and Generic Pediatric Quality of Life Questionnaire (PedsQLTM4.0). Clinical, immunological and virological data were retrieved from medical records. For statistical analysis, the Mann-Whitney and Qui-Square tests, and Spearman Correlation Coefficient were used. Results were considered statistically significant if P ? 0.05. The study was approved by the Committee of Ethics in Research in Human Beings from the Faculty of Medical Sciences, State University of Campinas. RESULTS: The prevalence of sleep disturbances, based on SDSC scores, was 77.4% in patients and 75% in controls (P = 0.67). HIV-infected patients showed higher SDSC scores in the respiratory sleep disturbances domain, with medians of 3 (3 - 15) vs 3 (3-11) (P = 0.05), and higher scores in EDSS, with medians of 6 (0 - 17) vs 5 (0 - 14) (P = 0.02). A correlation was observed between SDSC and PedsQL scores in both groups, with rs = -0,46 in the infected group (P < 0.001) and rs = -0.37 in the control group (P < 0.001). No statistically significant associations were observed between quality of sleep markers and clinical, immunological or virological variables, in the infected group. CONCLUSION: HIV-infected adolescents showed similar quality of sleep when compared to the healthy control population, yet with high prevalence of sleep disturbances in both groups. An association between quality of sleep and quality of life was observed in both groups. No clinical, immunological or virological issues were identified in the HIV-infected group in association to sleep quality. Such results are probably due to the gradative improvement of conditions of life in HIV-infected adolescents, as a result of successful antiretroviral therapy, and also to the vulnerabilities which potentially affect the quality of sleep in Brazilian adolescents / Mestrado / Saude da Criança e do Adolescente / Mestre em Saude da Criança e do Adolescente

Orientador: Marcos Tadeu Nolasco da Silva / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-18T22:53:13Z (GMT). No. of bitstreams: 1 Ernesto_AlineSantarem_M.pdf: 2616267 bytes, checksum: 8169b5c577c4b73c8dedf740de1f15b9 (MD5) Previous issue date: 2011 / Resumo: Introdução: A Síndrome de Imunodeficiência Adquirida (Aids) é atualmente uma doença crônica, controlável graças à Terapia Antirretroviral de Alta Atividade (TARV). Em um contexto de acesso universal ao tratamento, a adesão do paciente torna-se um fator limitante e desafiador. Este estudo teve como objetivo avaliar a prevalência da nãoadesão à TARV em uma coorte de crianças e adolescentes com o uso de instrumentos complementares, bem como identificar e compreender os fatores associados a ela. Casuística e Métodos: Estudo analítico, observacional, prospectivo do tipo corte transversal. A população foi composta por 108 pacientes infectados pelo Vírus da Imunodeficiência Humana (HIV) em TARV (60 meninos), com idades entre 8 e 19 anos. A adesão foi avaliada por meio de um questionário padronizado, consulta a registros de dispensação de farmácia (RDF) e uma escala de auto-eficácia. Foram entrevistados os responsáveis pela administração da medicação, cuidadores ou pacientes. Indivíduos que receberam menos de 95% das doses prescritas nas 24 horas ou nos 7 dias anteriores à entrevista, ou que apresentaram um intervalo maior que 37 dias no RDF nos três meses anteriores à entrevista, foram considerados não-aderentes. A escala de auto-eficácia forneceu um escore contínuo, com amplitude de 0 a 100. Foi avaliada a associação de variáveis independentes ligadas a condições demográficas, clínicas, imunológicas, virológicas, e psicossociais aos desfechos de adesão. Na análise estatística univariada foi utilizada a determinação de Odds Ratios (OR) para a comparação entre variáveis categóricas, o teste de Mann-Whitney para a comparação entre variáveis contínuas e categorias, e determinado Coeficiente de Correlação de Spearman (rs) para a comparação entre variáveis contínuas. Resultados foram considerados significativos com valor de p _ 0,05. Para o controle de variáveis de confundimento, foi utilizada a análise multivariada com o uso de regressão logística. O estudo foi aprovado pelo Comitê de Ética em Pesquisa em Seres Humanos da Faculdade de Ciências Médicas da Universidade Estadual de Campinas. Resultados: A prevalência de não-adesão variou entre 11,1% (pacientes não aderentes por 3 instrumentos), 15,8% (auto-relato de 24 horas), 27,8% (auto-relato semanal), 45,4% (RDF) e 56,3% (ao menos um dos 3 desfechos). Os auto-relatos de 24 horas e 7 dias, quando comparados ao RDF, mostraram baixa sensibilidade (29% e 43%, respectivamente) e alta especificidade (95% e 85%, respectivamente). As seguintes variáveis independentes apresentaram associação estatisticamente significativa com a não-adesão na análise univariada, de acordo com o instrumento: Auto-relato de 24 horas: dificuldade de administração pelo cuidador (OR = 9,11; IC95% = 2,87 - 28,98); paciente não-praticante de religião (OR = 2,76; IC95% = 0,92 - 8,32); intolerância à medicação (OR=4,61; IC95% =1,47 - 14,42); renda per capita (medianas de US$ 137,91 vs US$ 208,33; p = 0,016); número de ITRNs com mutações de resistência (medianas de 6 vs 1; p = 0,016); Auto-relato de 7 dias: dificuldade de administração pelo cuidador (OR = 2,91; IC95% = 1,05 - 8,12; administração da TARV pelo paciente (OR = 3,59; IC95% = 1,47 - 8,78); cuidador com 8 ou menos anos de escolaridade (OR = 3,25; IC95% = 1,03 - 10,30); paciente com mais de 8 anos de escolaridade (OR = 3,70; IC95% = 1,41 - 0,70); idade do paciente (medianas de 13,94 vs 12,94; p = 0,03); renda per capita (medianas de US$ 131,67 vs US$ 201,39; p = 0,009); Registro de dispensação de farmácia: dificuldade de administração pelo cuidador (OR = 3,19; IC95% = 1,11 - 9,17); administração da TARV pelo paciente (OR = 2,70; IC95% = 1,15 - 6,33); falha de controle virológico (OR = 3,70; IC95% = 1,67 - 8,33); falta a consulta nos últimos 6 meses (OR = 3,27 IC95% = 1,38 - 7,78); paciente nãopraticante de religião (OR = 2,47 IC95% = 1,10 - 5,57); cuidador não-praticante de religião (OR = 3,19; IC95% = 1,36 - 7,50); cuidador com emprego fora do domicílio (OR = 2,27; IC95% = 1,05 - 4,92); renda per capita (medianas de US$ 166,67 vs US$ 222,22; p = 0,014); As seguintes variáveis independentes apresentaram associação estatisticamente significativa com a não-adesão na análise multivariada, de acordo com o instrumento: Auto-relato de 24 horas: intolerância à medicação (OR = 9,11; IC95% = 2,87 - 28,98); Auto-relato de 7 dias: dificuldade de administração pelo cuidador (OR = 2,91; IC95% = 1,05 - 8,12); administração da TARV pelo paciente (OR = 3,59; IC95% = 1,47 - 8,78); classe socioeconômica C+D (3,54; 0,97 - 2,85); Registro de dispensação de farmácia: falha de controle virológico (OR = 3,73; IC95% = 1,68 - 8,31); falta a consulta nos últimos 6 meses (OR = 3,27 (IC95% = 1,38 - 7,78); cuidador não-praticante de religião (OR = 3,19; IC95% = 1,36 - 7,50); O escore de auto-eficácia teve mediana de 95,20 (11,90 - 100) e mostrou associação significativa com dificuldade de administração da medicação pelo cuidador (mediana de 78,5 vs 95,2; p = 0,001), falha de controle virológico (mediana de 90,4 vs 100; p = 0,001), administração da TARV pelo paciente (mediana de 89,8 vs 95,2; p = 0,05), falta à consulta nos últimos seis meses (mediana de 86,3 vs 100, p < 0,001), categoria clínica N, A ou B (mediana de 90,47 vs 100; p = 0,018), paciente não praticante de religião (mediana de 90,4 vs 95,2, p = 0,037), orfandade (mediana de 95,2 vs 90,4 p = 0,05), relação CD4/CD8 (rs = 0,220; p = 0,025), número de classes de antirretrovirais com resistência viral (rs = 0,583; p < 0,001), número de ITRNs com resistência viral (rs = 0,44; p = 0,009), renda per capita (rs = 0,302; p = 0,001), Escore PedsQL domínio emocional (rs = 0,265; p = 0,007). Conclusão: Na população estudada, observou-se alta prevalência de falha de adesão à TARV, com maior sensibilidade de detecção pela análise da retirada de medicamentos na farmácia. Adicionalmente, observou-se associação entre os escores de auto-eficácia e as categorias de adesão. Os instrumentos utilizados mostraram-se complementares na identificação de fatores de risco para a não-adesão. Com o objetivo de eliminar variáveis de confundimento, sete fatores foram identificados como associados a dificuldade de adesão: intolerância à medicação, dificuldade de administração da medicação pelo cuidador, responsabilidade de administração medicação pelo próprio paciente, classe socioeconômica mais baixa, ausência de controle virológico, cuidador não praticante de religião e faltas às consultas / Abstract: Background: The Acquired Immunodeficiency Syndrome (Aids) is currently a chronic disease, manageable by Highly Active Antiretroviral Therapy (HAART). In a setting of universal access to treatment, patient adherence arises as a limiting and challenging issue. This study aimed to evaluate the prevalence of nonadherence to HAART in a cohort of children and adolescents, using complementary instruments, and also identify and understand associated factors. Patients and Methods: Observational, analytical, prospective, cross-sectional study. The study population comprised 108 Human Immunodeficiency Virus (HIV) -infected patients on HAART (60 boys), from 8 to 19 years-old. Adherence was evaluated by a standardized questionnaire, pharmacy refill data (PRD) and a self-efficacy scale. Patients or caregivers were interviewed (whoever was in control of medicine administration). Patients who received less than 95% of prescribed doses in the 24 hours of 7 days before the interview, or who had a record of an interval of more than 37 days between refills, were considered nonadherent. The self-efficacy scale provided a continuous score, varying from 0 to 100. The association between adherence outcomes and independent variables related to demographical, clinical, immunological, virological and psychosocial conditions was estimated. Statistical analysis was performed with the use of Odds Ratios (OR) for comparison between categorical variables, Mann-Whitney test for comparison between continuous variables and categories, and Spearman Correlation Coefficient (rs) for comparison between continuous variables. Results were considered statistically significant if p _ 0.05. Confounding variables were controlled by multivariate analysis with logistic regression. The study was approved by the Human Research Ethics Committee of the State University of Campinas Faculty of Medical Sciences. Results: Nonadherence prevalence varied from 11.1% (nonadherent patients in 3 instruments), 15.8% (24-hour self-report), 27.8% (7-day self-report), 45.4% (PRD) and 56.3% (at least one of the outcomes). Self-reports from 24 hours and 7 days, when compared to PRD, showed low sensitivity (29% and 43%, respectively) and high specificity (95% and 85%, respectively). The following independent variables showed statistically significant association with nonadherence on univariate analysis, according to each instrument: Twenty-four hour self-report: difficulty of ministration by caregiver (OR = 9.11 ; 95%CI = 2.87 - 28.98); lack of religious practice by patient (OR = 2.76; 95%CI = 0.92 - 8.32); medication intolerance (OR=4.61; 95%CI =1.47 - 14.42); per capita income (median US$ 137.91 vs US$ 208.33; p = 0.016); number of nucleoside/nucleotide analogues (NRTIs) with resistant mutations (median 6 vs 1; p = 0.016); Seven-day self-report: difficulty of ministration by caregiver (OR = 2.91; 95%CI = 1.05 - 8.12; HAART ministration by the patient (OR = 3.59; 95%CI = 1.47 - 8.78); caregiver with 8 or less years of school attendance (OR = 3.25; 95%CI = 1.03 - 10.30); patient with 8 or more years of school attendance (OR = 3.70; 95%CI = 1.41 - 0.70); patient age (median 13.94 vs 12.94; p = 0.03); per capita income (median US$ 131.67 vs US$ 201.39; p = 0.009); Pharmacy refill data: difficulty of ministration by caregiver (OR = 3.19; 95%CI = 1.11 - 9.17); HAART ministration by the patient (OR = 2.70; 95%CI = 1.15 - 6.33); lack of virological control (OR = 3.70; 95%CI = 1.67 - 8.33); missed consultations in the former 6 months (OR = 3.27 (95%CI = 1.38 - 7.78); lack of religious practice by patient (OR = 2.47 (95%CI = 1.10 - 5.57); lack of religious practice by caregiver (OR = 3.19; 95%CI = 1.36 - 7.50); caregiver working outside the home (OR = 2.27; 95%CI = 1.05 - 4.92); per capita income (median US$ 166.67 vs US$ 222.22 ; p = 0.014); The following independent variables showed statistically significant association with nonadherence on multivariate analysis, according to each instrument: Twenty-four hour self-report: medication intolerance (OR = 9.11; 95%CI = 2.87 - 28.98); Seven-day self-report: difficulty of ministration by caregiver (OR = 2.91; 95%CI = 1.05 - 8.12); HAART ministration by the patient (OR = 3.59; 95%CI = 1.47 - 8.78); socioeconomical classes C+D (3.54; 0.97 - 2.85); Pharmacy refill data: lack of virological control (OR = 3.73; 95%CI = 1.68 - 8.31); missed consultations in the former 6 months (OR = 3.27 (95%CI = 1.38 - 7.78); lack of religious practice by caregiver (OR = 3.19; 95%CI = 1.36 - 7.50); The self-efficacy score had a median of 95.20 (11.90 - 100) and showed significant association with difficulty of ministration by caregiver (median 78.5 vs 95.2; p = 0.001), lack of virological control (median 90.4 vs 100; p = 0.001), HAART ministration by patient (median 89.8 vs 95.2; p = 0.05), missed consultations in the former 6 months (median 86.3 vs 100, p < 0.001), clinical categories N, A or B ( median 90.47 vs 100; p = 0.018), lack of religious practice by patient (median 90.4 vs 95.2, p = 0.037), being orphan (median 95.2 vs 90.4 p = 0.05), CD4/CD8 ratio (rs = 0.220; p = 0.025), number or antiretroviral classes with resistance (rs = 0.583; p < 0.001), number of NRTIs with resistance (rs = 0.44; p = 0.009), per capita income (rs = 0.302; p = 0.001), PedsQL score, emotional domain (rs = 0.265; p = 0.007). Conclusion A high prevalence of HAART nonadherence was observed in the study population, being pharmacy refill data the most sensitive measurement. Additionally, an association was observed between adherence outcomes and self-efficacy scores. The instruments employed showed complementarity in the recognization of nonadherence risk factors. Aiming to eliminate confounding variables, seven factors were identified as associated to lack of adherence: medication intolerance, difficulty of ministration by the caregiver, ministration of medicines by the patient, lower socioeconomic class, lack of virological control, lack of religious practice by the caregiver and missed consultations / Mestrado / Saude da Criança e do Adolescente / Mestre em Ciências

Orientadores: Marcos Tadeu Nolasco da Silva, Maria Marluce dos Santos Vilela / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T12:56:55Z (GMT). No. of bitstreams: 1 Ferreira_JosianeFrancisca_M.pdf: 1674494 bytes, checksum: 65421fb00fd3ba43536a3c494f244ecd (MD5) Previous issue date: 2012 / Resumo: INTRODUÇÃO: A adoção da Terapia Antirretroviral Combinada (TARC), proporcionou uma dramática melhora na sobrevida, na qualidade de vida e no controle clínico da infecção por HIV em pediatria. Em consequência do controle efetivo da replicação viral, observa-se reconstituição do sistema imune, que contribui para a redução da incidência dos quadros infecciosos. Neste contexto, a determinação da reconstituição imune em estudos observacionais pode fornecer marcadores para a avaliação da resposta à TARC. OBJETIVOS: Determinar a prevalência de recuperação imunológica associada à introdução da TARC em uma população pediátrica acompanhada em serviço de referência, bem como fatores associados à obtenção desta meta. MÉTODO: Estudo observacional, analítico, do tipo coorte histórico. Em 127 pacientes em TARC pelo período mínimo de 1 ano, avaliou-se a reconstituição imune, caracterizada por uma porcentagem de linfócitos T CD4+ 'maior ou igual' 25% ou valor absoluto considerado normal para a idade. RESULTADOS: Dos 127 pacientes avaliados, 117 (92,12%) obtiveram reconstituição ou preservação imune. Nos indivíduos com reconstituição ou preservação imune, a idade ao início da TARC foi significativamente inferior (p = 0,007), e os escores-z de peso e IMC foram significativamente superiores (p = 0,028 e 0,032, respectivamente). Em relação às categorias clínicas, observou-se uma proporção significativamente superior de indivíduos nas categorias N, A e B no grupo com reconstituição ou preservação imune (p = 0,05). As porcentagens de linfócitos T CD4+ e a relação CD4 / CD8, bem como a proporção de indivíduos nas categorias imunológicas 1 e 2, foram superiores no grupo com reconstituição ou preservação imune (p = 0,019, 0,018 e 0,005, respectivamente). CONCLUSÃO: Pudemos observar que, em crianças e adolescentes infectados por HIV em TARC, a reconstituição ou preservação imune estiveram associadas a uma idade mais jovem e à maior preservação imunológica e clínica ao início da terapia / Abstract: INTRODUCTION: The adoption of Highly Active Antiretroviral Therapy (HAART) provided a dramatic improvement in survival, quality of life and clinical management of HIV infection in children. As a result the effective control of viral replication, it is observed immune reconstitution, which contributes to reducing the incidence of infectious. In this context, the determination of immune reconstitution in observational studies can provide markers for assessing response to HAART. Objective: To determine the prevalence of immune recovery or preservation associated with the introduction of HAART in a pediatric population followed in a reference service, as well as factors associated with the attainment of this goal. Methods: Observational study, analytic, historical cohort. In 127 patients on HAART for at least one year, we evaluated the immune reconstitution or preservation, characterized by a of CD4+ cell percentage 'more or equal' 25% or absolute values considered normal for their age. Results: Of the 127 patients evaluated, 117 (92.12%) had immune reconstitution or preservation. In individuals with immune reconstitution or preservation, the age at first HAART was significantly lower (p = 0.007), and weight and BMI z-scores for age were significantly higher (p = 0.028 and 0.032, respectively). With respect to clinical categories, there was a significantly higher proportion of individuals in N, A and B categories in the immune reconstitution or preservation group (p = 0.05). The CD4+ cell percentages and CD4/CD8 ratios and the proportion of individuals in immunological categories 1 and 2, were higher in the group with immune reconstitution or preservation (p = 0.019, 0.018 and 0.005, respectively). Conclusion: In our cohort of HIV-infected children and adolescents, on HAART, the preservation of immunocompetence or immune reconstitution were associated to an earlier age and better immune and clinical preservation at the beginning of therapy / Mestrado / Saude da Criança e do Adolescente / Mestra em Saúde da Criança e do Adolescente

Magister Public Health - MPH / Antiretroviral therapy (ART) improves the quality of lives of people living with HIV/AIDS by suppressing HIV replication and improving the patient’s immunity. An improved immunity will help prevent patients from contracting opportunistic infections. Adherence to ART is vital to obtain good clinical outcome for patients. Defaulting ART leads to increase in viral load, decreased host immunity, development of HIV drug resistant strains, exposure to opportunistic infections and ultimately death. HIV positive patients who are on ART face many challenges in adhering to their medications, these challenges act as barriers to their adherence to treatment. This study explores the barriers that adult patients in a hospital in Eastern Cape of South Africa face while on treatment. These barriers include individual factors, socio-economic factors, health service factors, medical regimen factors.

INTRODUÇÃO: Com a evolução da terapêutica para a Síndrome da Imunodeficiência Adquirida e o conseqüente aumento da sobrevida, um número crescente de crianças e adolescentes passou a conviver com a infecção pelo vírus da imunodeficiência humana (VIH). Paralelamente, aumentou a prevalência de complicações da doença sendo que as cardiovasculares são as mais graves. O presente estudo teve por objetivo determinar a prevalência das alterações cardiovasculares em crianças e adolescentes soropositivas, comparando com soronegativas e a sua relação com variáveis sócio-demográficas e clínicas. MÉTODOS: Estudo observacional, transversal, do tipo caso-controle de 83 crianças e adolescentes soropositivas do ambulatório de infectologia do Hospital Infantil Joana de Gusmão (Florianópolis, Santa Catarina) comparada a 83 crianças e adolescentes soronegativas e aparentemente saudáveis. Foi aplicado questionário estruturado, foram realizados pesquisa em prontuários, exame físico e antropométrico, eletrocardiografia, radiografia de tórax, ecocardiografia e ultra-sonografia carotídea e foi coletado sangue para análises. Foram realizadas análises univariadas e bivariadas para determinação de diferenças entre os grupos e multivariadas por regressão logística, pelo método anterógrado condicional, para os desfechos VIH+, disfunção de ventrículo esquerdo e aumento da espessura médio-intimal carotídea. RESULTADOS: Alterações cardiovasculares foram encontradas em 88% das crianças e adolescentes soropositivos sendo que 31% delas apresentaram mais de duas alterações. Todas as crianças e adolescentes soropositivas apresentaram ao menos um fator ou marcador de risco para aterosclerose, sendo que 68% delas apresentaram mais de dois destes fatores. Após a análise multivariada, a condição VIH+ apresentou associação positiva com tempo de aceleração pulmonar diminuído [razão de chance (RC): 23,9(2,8-204,6), p = 0,004], espessamento médio-intimal [RC: 13,1(3,9-43,5), p < 0,001], proteína C reativa elevada [RC: 11,5(2,8-47,6), p = 0,001] e negativa com excesso de ingestão de gorduras saturadas [0,2(0,1-0,5), p = 0,001]. O espessamento médio-intimal associou-se positivamente com o uso de estavudina [RC: 18,9(2,5-145,6), p = 0,005], aumento da relação átrio esquerdo/aorta [RC: 15,6(1,6-154,6), p = 0,019], aumento de prega suprailíaca [RC: 7,9(1,5-41,9), p = 0,015], taquipnéia [RC: 5,9(1,2-29,3), p = 0,031], níveis elevados de linfócito T CD8+ [RC: 5,7(1,1-28,3), p = 0,033], baixos níveis de linfócito T CD4+ [RC: 5,5(1,2-24,6), p = 0,025]. Por outro lado, associou-se negativamente com níveis elevados de colesterol total [RC: 0,22(0,1-0,8), p = 0,025] e zênite de linfócito T CD8+ [RC: 0,1(0,1-0,5), p = 0,007]. A disfunção de ventrículo esquerdo associou-se positivamente à carga viral detectável [RC: 18,6(3,1-111,6), p = 0,001], ingestão de bebida alcoólica [RC: 10,7(1,7-66,5), p = 0,011], baixo peso ao nascimento [RC: 5,6(1,2-24,7), p = 0,025] e negativamente a veias proeminentes de membros superiores [RC: 0,15(0,03-0,7), p < 0,001]. CONCLUSÕES: Na amostra estudada, as crianças e adolescentes apresentaram altas prevalências de anormalidades cardiovasculares, assim como de fatores de risco para aterosclerose. Estas alterações encontradas, em especial as relacionadas a alterações vasculares precoces da aterosclerose, por sua forte associação com pior prognóstico cardiovascular, indicam a necessidade imediata de formulação de estratégias para seu controle / INTRODUCTION: The Highly Active Anti-Retroviral Therapy employed to acquired immunodeficiency syndrome treatment has increased survival rate of children and adolescents living with human immunodeficiency virus (HIV). The new concerns in this population are infection-related or drug-related complications, and the higher risk complications may be determined by cardiovascular involvement. This study aimed to determine cardiovascular abnormalities prevalence in HIV-infected children and adolescents, and associations among these abnormalities and socio-cultural and clinical variables and cardiovascular risk factors, when compared to HIV-negative children and adolescents. METHODS: An observational, cross-sectional, case-control study was carried out, comparing 83 HIV-infected children and adolescents from an outpatient ambulatory of infectology at Joana de Gusmão Childrens Hospital (Florianopolis, Santa Catarina State) and 83 healthy children from a cardiologic triage outpatient ambulatory, at the same hospital, without any cardiovascular structural abnormality. A questionnaire, research of clinical records, physical examination, anthropometry, electrocardiography, chest X-ray, echocardiography and carotid ultrasound examination were performed and fasting blood sample were collected. Student t, chi-square, Mann-Whitney and Fischer exact tests were performed for univariate and bivariate analysis. For the multivariate analysis, a logistic regression was applied by forward conditional method, to the outcomes HIV-positive, left ventricular dysfunction and thicken intima-media complex. RESULTS: Cardiac abnormalities were found in 88% of the HIV-infected children and adolescents, and in 31% of them there were more than 2 abnormalities. Atherosclerotic risk factors were found in all HIV-infected children and adolescents, and in 68% of them there were more than to risk factors. After multivariate analysis, HIV-infection were positively associated with low pulmonary artery systolic acceleration time [odds ratio (OR): 23.9(2.8-204.6), p = 0.004], thicken carotid intima-media complex [OR: 13.1(3.9- 3.9-43.5), p < 0.001], high C-reactive protein levels [OR: 11.5(2.8-47.6), p = 0.001] and negative association with excessive ingestion of saturated fat [OR: 0.2(0.1-0.5), p = 0.001]. The presence of thicken intima-media complex were positively associated with stavudine use [OR: 18.9(2.5-145.6), p = 0.005], high left atrium/aorta relation [OR: 15.6(1.6-154.6), p = 0.019], high suprailiac skinfold thickness [OR: 7.9(1.5-41.9), 0.015], tachypnea [5.9(1.2-29.3), p = 0.031], high CD8+ T cells count [OR: 5.7(1.1- 28.3), p = 0.033], low CD4+ T cells count [OR: 5.5(1.2-24.6), p = 0.025], and negatively associated with total cholesterol [OR: 0.22(0.1-0.8), 0.1-0.8), p = 0.025] and zenith of CD8+ T cells [OR: 0.1(0.1-0.5), p = 0.025]. Left ventricular dysfunction had a positive association with detectable HIV viral load [OR: OR: 18.6(3.1-111.6), p = 0.001], alcohol ingestion [OR: 10.7(1.7-66.5), p = 0.011], and low birthweight [OR: 5.6(1.2-24.7), p = 0.025] and a negative association with arms prominent veins [OR: 0.15(0.1-0.7), p < 0.001]. CONCLUSIONS: In this sample, we found high prevalence of cardiovascular abnormalities and atherosclerotic risk factors. These abnormalities, especially early cardiovascular markers of atherosclerosis, because are related to a poor cardiovascular prognosis, pointed that there is an urgent necessity to implement preventive strategies to control cardiovascular events in this population, in the next decades

Submitted by Ricardo Cedraz Duque Moliterno (ricardo.moliterno@uefs.br) on 2015-11-17T23:09:48Z No. of bitstreams: 1 Disserta??o Anderson Final Corre??es Banca Impress?o.pdf: 1523045 bytes, checksum: 814474d8f39dbb0905905b6e3a5d0af2 (MD5) / Made available in DSpace on 2015-11-17T23:09:48Z (GMT). No. of bitstreams: 1 Disserta??o Anderson Final Corre??es Banca Impress?o.pdf: 1523045 bytes, checksum: 814474d8f39dbb0905905b6e3a5d0af2 (MD5) Previous issue date: 2013-03-23 / After the discovery of the Human Immunodeficiency Virus (HIV), in the 1980s, the clinical and epidemiological characteristics of Acquired Immunodeficiency Syndrome (AIDS) have changed over the years, mainly from the second half of the 1990s, with the emergence of new drugs for its treatment. Objective: to investigate the oral condition and the HIV infection condition factors associated in individuals living with HIV/Aids. Method: a cross-sectional, descriptive, exploratory study. Single examiner used a data collection instrument in Assistance Specialized Services (SAE - STD/HIV/Aids) users in three municipalities in the Bahia State. The information derived from primary data (interviews and oral clinical examination) and secondary data (clinical records). Socio-demographic, lifestyle and health condition characteristics, HIV/Aids infection and oral condition were researched. Individuals registered in these services, with age greater than or equal to eighteen years old, gender both and that participate accepted voluntarily in the research were evaluated. Sample size was determined by convenience, from the data collection availability time. For statistical analysis, the Stata 10 statistical package used, the Chi-square test was used for categorical variables, with 5% significance level. Results: preliminary results in 228 individuals showed that the majority was male gender, browns, with a mean age 41.6 years old and the average HIV infection diagnosis time was 5.4 years. The HIV/Aids infection condition, as assessed by CD4 T-lymphocyte count showed statistically significant association with: current occupation, antiretroviral drugs use duration, last viral load determination and intra-oral injury presence. As for the oral condition, in relation to dental caries, the following factors significantly associated: age, race, current occupation, family income, average number of cigarettes per day, total and / or partial prosthesis use, prosthesis dental use, gingivitis and flossing. For intra-oral lesion presence was associated with age, educational level, current smoking, antiretroviral medications duration, dosage last viral load last count CD4 + T lymphocytes, CD4/CD8 ratio, gingivitis , periodontitis and flossing. Regarding the periodontitis, the following factors were associated: sex, residence county, past smoking, current smoking and flossing. Conclusions: the preliminary findings point to association between socio-demographic, lifestyle characteristics and HIV infection condition and oral condition, suggesting the need for better understanding of the influence of these variables in the individuals living with HIV/Aids monitoring, contributing to preventive measures, treatment and survival of the infection diagnosed individuals. / Ap?s a descoberta do V?rus da Imunodefici?ncia Humana (HIV), na d?cada de 1980, as caracter?sticas cl?nicas e epidemiol?gicas da S?ndrome da Imunodefici?ncia Adquirida (Aids) se modificaram ao longo dos anos, principalmente a partir da segunda metade da d?cada de 1990, com o surgimento de novos medicamentos para seu tratamento. Objetivo: Investigar fatores associados ? condi??o bucal e ? condi??o de infec??o pelo HIV em indiv?duos vivendo com HIV/Aids. M?todo: Foi realizado estudo do tipo transversal, de car?ter explorat?rio, atrav?s da coleta de dados com o uso de um instrumento de coleta aplicado por um ?nico examinador em usu?rios de Servi?os de Assist?ncia Especializada (SAE ? DST/HIV/Aids) de tr?s munic?pios do Estado da Bahia. As informa??es foram provenientes de dados prim?rios (entrevista e exame cl?nico bucal) e de dados secund?rios (prontu?rios cl?nicos). Foram pesquisadas caracter?sticas s?cio-demogr?ficas, relacionadas ao estilo de vida, ? condi??o de sa?de, ? infec??o HIV/Aids e ? condi??o bucal. Duzentos e vinte e oito indiv?duos cadastrados nesses Servi?os, com idade igual ou superior a dezoito anos, de ambos os sexos e que aceitaram, voluntariamente, participar da pesquisa foram avaliados. O tamanho da amostra foi determinado por conveni?ncia, a partir da disponibilidade de tempo para a coleta de dados. Para a an?lise estat?stica, foi utilizado o pacote estat?stico Stata 10, empregando-se o teste de Qui-quadrado para vari?veis categ?ricas, com n?vel de signific?ncia de 5%. Resultados: Os resultados preliminares mostraram que a maioria dos indiv?duos avaliados era do sexo masculino, pardos, com m?dia de idade de 41,6 anos e com tempo m?dio de diagn?stico da infec??o pelo HIV de 5,4 anos. A condi??o de infec??o HIV/Aids, avaliada pela contagem de linf?citos T CD4+ mostrou associa??o estatisticamente significante com: ocupa??o atual, tempo de uso de medica??es antirretrovirais, ?ltima dosagem de carga viral e presen?a de les?o intra-oral. Quanto ? condi??o bucal, em rela??o ? presen?a de c?rie dent?ria, os seguintes fatores apresentaram associa??o estatisticamente significante: idade, ra?a/cor, ocupa??o atual, renda familiar, quantidade m?dia de cigarros por dia, uso de pr?tese dent?ria total e/ou parcial, necessidade de uso de pr?tese dent?ria, presen?a de gengivite e uso de fio dental. Para a presen?a de les?o intra-oral, houve associa??o com: idade, n?vel de escolaridade, tabagismo atual, tempo de uso de medica??es antirretrovirais, ?ltima dosagem de carga viral, ?ltima contagem de linf?citos T CD4+, rela??o CD4/CD8, presen?a de gengivite, presen?a de periodontite e uso de fio dental. Com rela??o ? presen?a de periodontite, os seguintes fatores apresentaram associa??o: sexo, munic?pio de resid?ncia, tabagismo no passado, tabagismo atual e uso de fio dental. Conclus?o: Os achados preliminares apontam para a associa??o entre fatores s?cio-demogr?ficos e de estilo de vida ? condi??o de infec??o HIV e ao estado bucal, sugerindo a necessidade de melhor conhecimento da influ?ncia destas vari?veis no acompanhamento dos indiv?duos que vivem com HIV/Aids, contribuindo para medidas preventivas, tratamento e sobrevida daqueles com diagn?stico da referida infec??o.

Philosophiae Doctor - PhD / The continued success of antiretroviral programmes in the treatment of HIV is dependent on access to a cost-effective HIV drug resistance test (HIV-DRT). HIVDRT involves sequencing a fragment of the HIV genome and characterising the presence/absence of mutations that confer resistance to one or more drugs. HIV-DRT using conventional DNA sequencing is prohibitively expensive (~US$150 per patient) for routine use in resource-limited settings such as many African countries. While the advent of ultra deep pyrosequencing (UDPS) approaches have considerably reduced (3-5 fold reduction) the cost of generating the sequence data, there has been an even more significant increase in the volume of data generated and the complexity involved in its analysis. In order to address this issue we have developed Seq2Res, a computational pipeline for HIV drug resistance test from UDPS genotypic data. We have developed QTrim, software that undertakes high throughput quality trimming of UDPS sequencing data to ensure that subsequently analyzed data is of high quality. The comparison of QTrim to other widely used tools showed that it is equivalent to the next best method at trimming good quality data but outperforms all methods at trimming poor quality data. Further, we have developed, and evaluated, a computational approach for the analysis of UDPS sequence data generated using the novel Primer ID that enables the generation of a consensus sequence from all sequence reads originating from the same viral template, thus reducing the presence of PCR and sequencing induced errors in the dataset as well as reducing. We see that while the Primer ID approach does undoubtedly reduce the prevalence of PCR and sequencing induced errors, it artificially reduces the diversity of the subsequently analysed data due to the large volume of data that is discarded as a result of there being an insufficient number of sequences for consensus sequence generation. We validated the sensitivity of the Seq2Res pipeline using two real biological datasets from the Stanford HIV Database and five simulated datasets The Seq2Res results correlated fully with that of the Stanford database as well as identifying a drug resistance mutations (DRM) that had been incorrectly interpreted by the Stanford approach. Further, the analysis of the simulated datasets showed that Seq2Res is capable of accurately identifying DRMs at all prevalence levels down to at least 1% of the sequence data generated from a viral population. Finally, we applied Seq2Res to UDPS resistance data generated from as many as 641 individuals as part of the CIPRA-SA study to evaluate the effectiveness of UDPS HIV drug resistance genotyping in resource limited settings with a high burden of HIV infections. We find that, despite the FLX coverage being almost three times as much as that of the Junior platform, resistance genotyping results are directly comparable between both of the approaches at a range of prevalence levels to as low as 1%. Further, we find no significant difference between UDPS sequencing and the "gold standard" Sanger based approach, thus indicating that pooling as many as 48 patient's data and sequencing using the Roche/454 Junior platform is a viable approach for HIV drug resistance genotyping. Further, we explored the presence of resistant minor variants in individual's viral populations and find that the identification of minor resistant variants in individuals exposed to nevirapine through PMTCT correlates with the time since exposure. We conclude that HIV resistance genotyping is now a viable prospect for resource limited setting with a high burden of HIV infections and that UDPS approaches are at least as sensitive as the currently used Sanger-based sequencing approaches. Further, the development of Seq2Res has provided a sensitive, easy to use and scalable technology that facilitates the routine use of UDPS for HIV drug resistance genotyping.

From the early 1990s, rates of HIV infection increased dramatically in South Africa and by the early 2000s, AIDS emerged as the main cause of death for adult South Africans. During the first half of the 2000s, the South African government’s response to this crisis was inadequate, marked by denial and delays in implementing prevention and treatment, resulting in thousands of preventable deaths. Yet, apart from the challenges posed by the predominantly urban-based Treatment Action Campaign (TAC), the absence of a social response to this crisis is notable, especially in rural settings. This scenario forms the broad backdrop to this ethnographic study that draws on participant observation and interviews undertaken over a three-year period (2002-2005) in KwaBomba village previously in the Gazankulu Homeland, now located in the Bushbuckridge municipality of the South African lowveld. An ethnographic perspective provides an intimate vantage point from which to view peoples’ experiences of the AIDS epidemic and their responses in context. This perspective draws attention to gaps in public health and biomedical understandings of the epidemic and suggests alternatives to these understandings. In Bushbuckridge, mortality and morbidity due to AIDS became visible in the late 1990s and early 2000s. Households were incapable of dealing with the burden of illness and death while the health services were often unwilling and ill-prepared. HIV prevention campaigns based on individual behaviour change were not well suited to a context in which HIV spread through sexual networks. Despite widespread awareness of the threat of AIDS, the disease was subjected to public censorship and AIDS suffering was concealed. Public discourses of AIDS were hidden within gossip and rumour and articulated as witchcraft suspicions and accusations. Although these discourses appear to deny and suppress the reality of AIDS, I suggest that they are active attempts to deal with the AIDS crisis: gossip and rumour allocate blame and construct a local epidemiology through which the epidemic can be surveilled; interpreting AIDS as witchcraft creates the possibility of avenging untimely death. These discursive forms are critical in informing individual and social responses to the AIDS epidemic. While the absence of public acknowledgement of AIDS as a cause of illness and death suggests denial and fatalism and appears to limit public action, subaltern discourses create shared secrets to manage the AIDS epidemic at the local level. Furthermore, these discourses may constitute a form of resistance against biomedical models of causality. Ethnographic enquiry at the local level offers a nuanced understanding of social responses to the AIDS epidemic. By examining forms of expression that lie outside the domain of public health, the thesis reveals how these constitute significant forms of social action in response to the epidemic. / Thesis (PhD)--University of Pretoria, 2012. / Anthropology and Archaeology / unrestricted

Philosophiae Doctor - PhD / In the decade since first identified, the Acquired Immunodeficiency syndrome (AIDS) has become a serious global disease. The nature of the Human Immunodeficiency Virus (HIV) that causes AIDS, whereby a carrier may be asymptomatic yet remain infectious, has enabled its dramatic spread. The number of AIDS cases is increasing exponentially, averaging a doubling time of between 8-15 months in different countries. Of the millions of HIV carriers, it is now estimated that all will eventually go on to develop full-blown AIDS and probably die within 15 years. Unlike other infectiqus diseases, there is currently no known vaccine or cure. Further, HIV is now virtually completely dependent on volitional sexual behaviours for transmission to occur. It is therefore an entirely preventable disease. However, since the behaviours that contribute to HIV-transmission are influenced by biological, psychological, and social factors, their alteration in line with safer sexual practices has been shown to be considerably complex and difficult. Intervention strategies that have relied on imparting knowledge about the disease have achieved limited success in influencing behaviour change. Unsafe sexual practices, and the risk of HIV-infection, often continue even when knowledge regarding prevention is adequate. It has therefore become apparent that other variables intrude which may mediate between knowledge acquisition, attitude formation, and consequent sexual behaviours. There appear to be no models which adequately explain the complexities in this area, and which enable adequate intervention strategies to be developed. The present study was undertaken to redress this problem, and to explore those variables that mediate in the area. Various psychological and social factors appear to be implicated in influencing sexual attitudes and behaviours. In order to adequately test the impact of psychosocial variables that were found to have significant associations in an exploratory study, a measuring instrument was developed. The AIDS Psychosocial Scale was statistically validated using content, frequency, factor, and reliability analyses and included psychological factors of self concept, defenses of denial, repression, and rationalisation, perceived empowerment in the form of locus of control and selfefficacy, and the social factor of peer pressure susceptibility. The impact of these psychosocial variables on indices of knowledge, condom attitude, and sexual practices, and on other epidemiological variables was tested using a sample of students at the University of the Western Cape (n=308). Results indicated a number of correlational and causal links between variables, confirming the mediational role psychosocial factors have in influencing knowledge acquisition, attitude formation, and behaviour outcome. A profile of lower self concept, higher defenses, lower self-efficacy, more external locus of control, and higher peer pressure susceptibility emerged which was associated with poorer knowledge, more negative attitudes, and higher unsafe sex. Based on this study, a model of psychosocial mediation is developed and its implications for intervention strategies discussed.

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